NBME Clinical Mastery Series Medicine Form 1

[PeurtoRico]

49. A 37 year old woman with chronic renal failure has multiple episodes of hypotension during hemodialysis. Examination shows distended neck veins, clear lung fields and distant heart sounds with no audible murmur or gallop. Echocardiography shows a large pericardial effusion. Which of the following signs is associated with the cause of hypotensive episodes?

A) Atypical systolic murmur
B) Auscultatory gap
C) Paradoxical pulse
D) S4
E) Widened pulse pressure

I marked B and that's wrong. On re-reading, I think it should be C: Paradoxical pulse. Any thoughts, jury?

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[lordman]

What does the jury have to say about this from form 1:

A 77-year-old woman comes to the physician because of a 1-year history of progressive swelling of the ankles and a 3-month history of shortness of breath with exertion. She has not had chest pain, orthopnea, or paroxysmal dyspnea. She takes hydrochlorothiazide for hypertension, verapamil for paroxysmal atrial tachycardia, and levothyroxine for hypothyroidism. Her blood pressure is 145/72 mmHg, pulse is 78/min and regular, and respirations are 18/min. there is no jugular venous distention. The lungs are clear to auscultation. Examination shows large superficial venous varicosities on the lower extremities and moderate ankle and pedal edema bilaterally. There is loss of hair and mild hyperpigmentation over the legs. Oxygen saturation is 96% at rest and 90% with exertion. An X-ray of the chest and ECG shows no abnormalities. Ventilation-perfusion lung scans show two subsegmental perfusion with defects but no ventilation abnormalities. Echocardiography shows mitral annular calcifications.

Which of the following is the most likely explanation for this patient’s dyspnea?


A Cardiac emboli secondary to intermittent arrhythmia
B Coronary ischemia (wrong answer)
C Left ventricular diastolic dysfunction
D Mitral insufficiency
E Recurrent pulmonary emboli

Someone said C, but I have failed to UNDERSTAND this question altogether.

I picked E and it was correct. I tagged you in the other thread!

 

[PeurtoRico]

The other thread had form 2 questions too so I shielded my eyes. Lol. I'll do form 2 next week - need to power through UW atm. Thanks!!

 

[CaliAtenza]

I picked E and it was correct. I tagged you in the other thread!

Oh I could totally see how they could lead you off into picking other things on that question; the sneaky bastards put the V/Q defect at the end. A good way to get to the correct answer; plug in the other answer choices and see if they fit. Coronary Ischemia doesn't cause a V/Q defect. Initially, the patient presents as if she has cardiac insuficiency (swelling of lower limbs, SOB with exertion). You would keep thinking that too, because of the other findings in the case, until you get to the very end .

 

[CaliAtenza]

Thanks! Good luck with the result - you'll be great, hopefully.

There were a few that were longer than Uworld. It could also have been the test software, making it seem longer, when they really weren't (paragraph spacing, etc). Yeah hopefully I'll be great lol; I keep thinking about potential stupid mistakes and its eating at me .

 

[CaliAtenza]

@lordman, regarding pagets case, i checked that in the early phase of the disease, ALK Phos can be normal.

Interesting. Something Uworld doesn't touch on (Every question about Pagets has the ALK Phos way up).

 

[PeurtoRico]

Yeahh.. The NBME question had Alk Phos of 100. So high-normal!

 

[CaliAtenza]

Yeahh.. The NBME question had Alk Phos of 100. So high-normal!

If its high normal, and that's the only thing that's up, then it would make sense to pick Pagets. Usually Uworld will give you values like 300-400, something like that. But the description that you provided earlier, of the pathology, would make it appropriate to choose pagets.

 

[PeurtoRico]

For how long do the wrong answers on NBME forms stay on your account? I was wondering if I need to copy them somewhere for review a day before exam or will I still be able to access it in 3 weeks from now (4 weeks from the time of purchase)?

 

[CaliAtenza]

For how long do the wrong answers on NBME forms stay on your account? I was wondering if I need to copy them somewhere for review a day before exam or will I still be able to access it in 3 weeks from now (4 weeks from the time of purchase)?

They stay there as long as you keep the account. My old Step 1 NBMEs are still there.

 

[PeurtoRico]

Actually, I just went back and checked that. You're right, thankss!

 

[Dhenki]

Oh that answer is cholesterol. I picked that and got it right. I think cholesterol screening begins at 35 for men, but he was 32 so I don't know why that's right… maybe it was the closest. If you come across screening guidelines for cholesterol, please post it up here as well. Thanks!
And the second answer is dextrose 5% because it was hypoglycemia.

Did you ever figure out why NBME says to screen for cholesterol at 32 instead of the standard 35 yrs.? I looked up guidelines and all of them say to start screening at 35 in men if there are no risk factors, which this guy clearly didn't have. I put CBC...

 

[Dhenki]

52 yo. woman with breast cancer is brought into the ED after 103F fever, chills, and generalized malaise. She receives chemo via an indwelling catheter. Last treatment was 3 wks. ago and she was in the hospital 1 mo. ago for pneumonia. She had diarrhea 2 days ago. Takes prochlorperazine, lorazepam, and sertraline. Tachycardiac, tachypenic, and hypotensive. Normal O2 sat. No erythema at catheter site and lungs are CTA. 2/6 systolic murmur on upper left sternal boarder. Normal UA, leukocyte count = 3200 with segmented neutrophils = 70%. CXR normal.

In addition to ceftazidime, you add vancomycin to cover MRSA due to recent hospital visits, but WHAT does this pt. actually have? I can't figure out the diagnosis.

Anyone know??

 

[Dhenki]

So sepsis causes ATN, which show up as granular casts in the urine. In one of the questions the pt. clearly had pyelonephritis, but the granular casts through me off and I choose ATN.

87 yo. with severe dementia has fever, chills, and lethargy x 2 days. 101F temp with CVA tenderness.
Leukocyte = 18,000
Urine- 20 RBCs, 50 WBCs, (+) granular casts, and few bacteria.

Dx?

A) AIN
B) Glomerulonephritis.
C) Pyelonephritis.
D) Retroperitoneal Abscess.
E) Tubular Necrosis.

 

[ZGX]

So sepsis causes ATN, which show up as granular casts in the urine. In one of the questions the pt. clearly had pyelonephritis, but the granular casts through me off and I choose ATN.

87 yo. with severe dementia has fever, chills, and lethargy x 2 days. 101F temp with CVA tenderness.
Leukocyte = 18,000
Urine- 20 RBCs, 50 WBCs, (+) granular casts, and few bacteria.

Dx?

A) AIN
B) Glomerulonephritis.
C) Pyelonephritis.
D) Retroperitoneal Abscess.
E) Tubular Necrosis.

 

[Dhenki]

52 yo. woman with breast cancer is brought into the ED after 103F fever, chills, and generalized malaise. She receives chemo via an indwelling catheter. Last treatment was 3 wks. ago and she was in the hospital 1 mo. ago for pneumonia. She had diarrhea 2 days ago. Takes prochlorperazine, lorazepam, and sertraline. Tachycardiac, tachypenic, and hypotensive. Normal O2 sat. No erythema at catheter site and lungs are CTA. 2/6 systolic murmur on upper left sternal boarder. Normal UA, leukocyte count = 3200 with segmented neutrophils = 70%. CXR normal.

In addition to ceftazidime, you add vancomycin to cover MRSA due to recent hospital visits, but WHAT does this pt. actually have? I can't figure out the diagnosis.

Anyone know??

I'm wrong. The new murmur and the fact that she has an indwelling catheter means that she has endocarditis, that's why vanc is the right answer.

 

[Toomanyoptions]

Thanks a bunch!
So here are a few more:

For each patient with jaundice, select the most likely diagnosis:

a) acute hepatitis
b) alpha-1 antitrypsin deficiency
c) biliary atresia
d) cholangiocarcinoma
e) choledocholithiasis (that's what I marked, and is wrong)
f) Gilberts
g) G6PD deficiency
h) Liver abscess
i) Peptic ulcer disease

2. A 25 year old woman comes to the physician because of a 5 day history of fatigue, nausea, and decreased appetite. Her temp is 37 C, Pulse 86/min, BP 110/50. She is told that she has a viral infection and is sent home. One week later, she returns because of continued fatigue and jaundice. Now her pulse is 80/min, respiratory 12/min, and BP 110/64. Examination shows scleral icterus. CVS examination normal. Liver edge is palpable 1cm below the right coastal margin, and is slightly enlarged, smooth and tender to palpation. Labs show:
Hb 13.2
Total bili 4.2
Direct bili 3.6
Alk Phos 120
AST 350
ALT 280
LDH 410

Could it be A or H?

First one is Gilberts.

Second one is A

 

[Toomanyoptions]

What does the jury have to say about this from form 1:

A 77-year-old woman comes to the physician because of a 1-year history of progressive swelling of the ankles and a 3-month history of shortness of breath with exertion. She has not had chest pain, orthopnea, or paroxysmal dyspnea. She takes hydrochlorothiazide for hypertension, verapamil for paroxysmal atrial tachycardia, and levothyroxine for hypothyroidism. Her blood pressure is 145/72 mmHg, pulse is 78/min and regular, and respirations are 18/min. there is no jugular venous distention. The lungs are clear to auscultation. Examination shows large superficial venous varicosities on the lower extremities and moderate ankle and pedal edema bilaterally. There is loss of hair and mild hyperpigmentation over the legs. Oxygen saturation is 96% at rest and 90% with exertion. An X-ray of the chest and ECG shows no abnormalities. Ventilation-perfusion lung scans show two subsegmental perfusion with defects but no ventilation abnormalities. Echocardiography shows mitral annular calcifications.

Which of the following is the most likely explanation for this patient’s dyspnea?


A Cardiac emboli secondary to intermittent arrhythmia
B Coronary ischemia (wrong answer)
C Left ventricular diastolic dysfunction
D Mitral insufficiency
E Recurrent pulmonary emboli

Someone said C, but I have failed to UNDERSTAND this question altogether.

The right answer is E. When you start thinking about it, it makes sense

 

[Toomanyoptions]

It has to be H. Nothing else makes sense here. Its clearly not anything else from what I can see.

I picked H and got it right.

 

[Toomanyoptions]

I chose E and it was wrong too....The CK is high!

I picked A and got it right. Also noted how fast her disease is progressing.

 

[Nellie109]

Is anyone interested in going over the CMS form 1 medicine with me?

 

[CodeRedDew]

Is anyone interested in going over the CMS form 1 medicine with me?

Pm me

 

[doctorbunny]

Help with a few more pretty please?

31. Healthy 72 yo woman in ED after being found on floor. Tripped and fell 2 days ago, couldn't get up. Alert, lethargic, pain in right hip. Pulse 140 regular
BP 88/54 mmHg
PE shows dry mucus membranes, dry axillary, R leg is shorter than L and held in external rotation.
Hb 17.5
Leuk's 14,500
Serum Na 155
Glucose 295
Xray shows fracture of femoral neck. Most appropriate next step?
A. IV 5% dextrose in water only
B. IV 5% dextrose in water + subQ insulin
C. IV dopamine
D. IV 0.45% saline *wrong
E. IV 0.9% saline
F. SubQ insulin only


34. 37 yo white woman w 2 days of painful pumps on her right index finger. 3 years ago same thing resolved without tx. No relevant PMH, no medications. Works as respiratory therapist. PE shows tender lesions. No other abnormalities. Which of the following is the most appropriate?
A. topical betamethasone
B. oral acyclovir
C. oral dicloxacillan *wrong
D. IV cefazolin
E. surgical incision + drainage

 

[climb_every_mountain]

P 88/54 mmHg
PE shows dry mucus membranes, dry axillary, R leg is shorter than L and held in external rotation.
Hb 17.5
Leuk's 14,500
Serum Na 155
Glucose 295
Xray shows fracture of femoral neck. Most appropriate next step?
A. IV 5% dextrose in water only
B. IV 5% dextrose in water + subQ insulin
C. IV dopamine
D. IV 0.45% saline *wrong
E. IV 0.9% saline
F. SubQ insulin only

Did you ever figure this one out?

 

[climb_every_mountain]

72 y/o M with 2 month h/o red tinged urine. HTN, emphysema, lung cancer. Takes HCTZ, K and albuterol. Prostate is firm and diffusely enlarged.
HCT 38%
MCV 78
PLTS 140
Cr 1.4
PSA 4.3
Urine
Protein trace
RBC 50-100
WBC 0-2

Most likely underlying cause?
Bacterial invasion of urogenital epithelium
Deposition of IgA in renal mesangium
Malignant transformation of epithelial cells
Mechanical irritation of ureteral epithelium
Platelet dysfunction

Correct answer is C. but i'm struggling to fully understand this?

 

[doctorbunny]

72 y/o M with 2 month h/o red tinged urine. HTN, emphysema, lung cancer. Takes HCTZ, K and albuterol. Prostate is firm and diffusely enlarged.
HCT 38%
MCV 78
PLTS 140
Cr 1.4
PSA 4.3
Urine
Protein trace
RBC 50-100
WBC 0-2

Most likely underlying cause?
Bacterial invasion of urogenital epithelium
Deposition of IgA in renal mesangium
Malignant transformation of epithelial cells
Mechanical irritation of ureteral epithelium
Platelet dysfunction

Correct answer is C. but i'm struggling to fully understand this?

Did it mention 'painless' blood tinged urine? He is also probably a smoker, as he has hx of lung cancer and emphysema. You can basically assume an elderly smoker man with painless hematuria has bladder cancer until proven otherwise.


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[climb_every_mountain]

Treatment for 62 y/o M with acute prostatitis?

Ampicillin
Azithro
Cipro
Nitrofurantoin
Tetracycline

I'm guessing Cipro but not sure.

 

[climb_every_mountain]

56 y/o M with worsening SOB over 6 months. mild LE edema and crackles. dilated left & right ventricles. diagnosis?

ASD
cardiomyopathy
chronic pulm emboli
cor pulmonale (wrong)
rhabdomyocarcoma

 

[doctorbunny]

56 y/o M with worsening SOB over 6 months. mild LE edema and crackles. dilated left & right ventricles. diagnosis?

ASD
cardiomyopathy
chronic pulm emboli
cor pulmonale (wrong)
rhabdomyocarcoma

View attachment 213192

Looks like dilated cardiomyopathy to me. In the CXR you can see the left ventricle is enlarged... in cor pulmonale you would expect an enlarged pulmonary artery/Hilar area with extra vascular markings in the lungs and potentially an enlarged right ventricle.



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[climb_every_mountain]

62 y/o M 8 month h/o progressive hand pain, stiffness. 1 year of fatigue and increased urination. Exam shows dark brown skin. Normal S1, S2 with S3 at apex. Tender over 2nd and 3rd MCPs without synovial thickening. Heberden nodes on multiple DIP joints.
Labs normal except mildly elevated AST, ALT, glucose 182. Rheumatoid factor negative.
Which of the following is most appropriate to confirm diagnosis?
HLA typing
measure serum copper concentration (wrong)
measure serum ferritin concentration
serum ANA
serum rheumatoid factor assay

this guy has hand OA but i'm confused which test is best, they already show you rheumatoid factor negative, is it ferritin concentration since he is fatigued?...

 

[climb_every_mountain]

52 y/o F on chemo for non-hodgkin lymphoma, with 2 day h/o painful rash on abdomen. Temp 38.5°. Exam shows vesicular rash over left and right lower quadrants with numerous similar lesions on the back. Best next step?
Advise to keep areas clean
IV Acyclovir therapy
IV broad spectrum abx
Oral analgesic and diphenhydramine therapy
Topical hyrdocortisone

Is this just plain HSV that needs Acyclovir? or is this something specifically associated with chemo treatment?

 

[doctorbunny]

62 y/o M 8 month h/o progressive hand pain, stiffness. 1 year of fatigue and increased urination. Exam shows dark brown skin. Normal S1, S2 with S3 at apex. Tender over 2nd and 3rd MCPs without synovial thickening. Heberden nodes on multiple DIP joints.
Labs normal except mildly elevated AST, ALT, glucose 182. Rheumatoid factor negative.
Which of the following is most appropriate to confirm diagnosis?
HLA typing
measure serum copper concentration (wrong)
measure serum ferritin concentration
serum ANA
serum rheumatoid factor assay

this guy has hand OA but i'm confused which test is best, they already show you rheumatoid factor negative, is it ferritin concentration since he is fatigued?...

Yah- so they're looking for you to suspect hemochromatosis. Elevated LFTs, golden skin, arthritis, hyperglycemia... ferritin would be best choice here.


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[doctorbunny]

52 y/o F on chemo for non-hodgkin lymphoma, with 2 day h/o painful rash on abdomen. Temp 38.5°. Exam shows vesicular rash over left and right lower quadrants with numerous similar lesions on the back. Best next step?
Advise to keep areas clean
IV Acyclovir therapy
IV broad spectrum abx
Oral analgesic and diphenhydramine therapy
Topical hyrdocortisone

Is this just plain HSV that needs Acyclovir? or is this something specifically associated with chemo treatment?

Did they give you a picture or anything? Chemo pt is at high risk for shingles bc he's immunocompromised, so I think you are right about the acyclovir... But it seems like the question maybe would've given you just a little more info so that you could be more sure of this answer?


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[Vc93]

I

62 y/o M 8 month h/o progressive hand pain, stiffness. 1 year of fatigue and increased urination. Exam shows dark brown skin. Normal S1, S2 with S3 at apex. Tender over 2nd and 3rd MCPs without synovial thickening. Heberden nodes on multiple DIP joints.
Labs normal except mildly elevated AST, ALT, glucose 182. Rheumatoid factor negative.
Which of the following is most appropriate to confirm diagnosis?
HLA typing
measure serum copper concentration (wrong)
measure serum ferritin concentration
serum ANA
serum rheumatoid factor assay

this guy has hand OA but i'm confused which test is best, they already show you rheumatoid factor negative, is it ferritin concentration since he is fatigued?...

It's, hemochromatosis